TELUS Health Assure Claims Pharmacy Manual

Introduction

The TELUS Health Assure Claims Pharmacy Manual serves as a comprehensive guide for pharmacies participating in the TELUS Health Assure claims network. This document outlines the procedures, requirements, and guidelines that pharmacies must follow when processing claims through the TELUS Health system. Understanding and implementing these protocols ensures efficient claims processing, reduced administrative burden, and improved client satisfaction.

Overview of TELUS Health Assure

TELUS Health Assure is a leading health benefits management system that connects pharmacies, insurers, and patients in a streamlined benefits processing network. The Assure platform enables real-time claims adjudication, drug coverage verification, and comprehensive drug plan management. Through this system, pharmacies can process prescription claims efficiently, reducing out-of-pocket expenses for plan members and ensuring accurate reimbursement.

Claims Submission Process

The pharmacy claims submission process under TELUS Health Assure involves several key steps:

• Eligibility Verification: Before processing a claim, the pharmacy must verify the patient's eligibility through the Assure system. This confirms that the patient is covered under a participating plan.
• Drug Coverage Check: Pharmacies should confirm whether the prescribed medication is covered under the patient's drug plan, including any formulary restrictions or prior authorization requirements.
• Claim Submission: Using their pharmacy management system, the pharmacy submits the claim with all required information including patient details, prescriber information, drug details, and dispensing information.
• Real-time Adjudication: TELUS Health Assure processes the claim in real-time, providing an immediate response regarding coverage, copayment amounts, and rejection reasons if applicable.
• Response Handling: Pharmacy staff must appropriately respond to claim responses, including providing patient education on copayment, plan coverage, and any alternative medications if necessary.

Required Claim Information

Accurate and complete information is crucial for successful claims processing. The TELUS Health Assure system requires specific data elements for each claim submission, including:

• Patient identification (name, date of birth, identification number)
• Drug identification (DIN, drug name, strength, dosage form)
• Prescriber information (name, license number)
• Prescription details (date written, quantity, days supply)
• Patient copayment amount
• Pharmacy identification details

Incomplete or inaccurate claim submissions will result in rejections and delays in payment. Pharmacies should implement quality control measures to minimize errors.

Common Claim Rejections

Understanding common claim rejection reasons helps pharmacies improve their claims submission processes and reduce rejections. Frequent rejection reasons include:

• Patient Ineligibility: The patient is not currently covered under the plan or the identification provided does not match records.
• Drug Not Covered: The prescribed medication is not included in the plan's formulary.
• Prior Authorization Required: The medication requires prior approval before dispensing.
• Quantity Limit Exceeded: The dispensed quantity exceeds the maximum allowed by the plan.
• Refills Not Authorized: Claiming a refill that was not prescribed or authorized.
• Duplicate Claim: Submitting a claim for a prescription that has already been processed.
• Technical Errors: Data formatting issues, missing required fields, or system connectivity problems.

Plan Types and Coverage Variations

TELUS Health Assure processes claims for various types of benefit plans, each with specific coverage parameters:

• Basic Drug Plans: Cover essential medications with formulary restrictions.
• Comprehensive Drug Plans: Provide broader coverage including formulary and non-formulary drugs.
• Specialty Drug Plans: Focus on high-cost specialty medications with specific coverage criteria.
• Managed Care Plans: Implement additional utilization management techniques such as step therapy, prior authorization, and therapeutic substitution.

Pharmacy staff should be familiar with the coverage parameters of plans they regularly process claims for to better assist patients and navigate formulary restrictions.

Special Claims Scenarios

The TELUS Health Assure Claims Pharmacy Manual provides guidance for handling special claims scenarios, including:

• Compounded Prescriptions: Claims for compounded medications require specific billing procedures and documentation.
• Medical Supplies: Non-drug medical supplies may be claimable under certain plans with appropriate billing.
• Emergency Supplies: Temporary emergency medication supplies may be processed through special procedures.
• Billing for Non- Covered Medications: Processes for submitting claims to secondary payers when the primary plan does not cover a medication.
• Retroactive Claims: Procedures for submitting past claims when systems were unavailable or other exceptional circumstances prevented timely submission.

Error Resolution and Appeals

When claims are rejected disputed amounts arise, pharmacies have specific pathways for resolution:

• Claim Corrections: Simple errors (data entry mistakes) should be corrected by voiding the original claim and submitting a correct version.
• Plan Exception Requests: For medications not normally covered, pharmacies may initiate exception requests on behalf of patients when clinically appropriate.
• Appeals Process: When coverage decisions appear incorrect, pharmacies may initiate formal appeals following the procedures outlined in the manual.
• Contact with Payer: The manual provides guidance on appropriate escalation paths and contact information for resolving complex issues.

Pharmacy Responsibilities

Pharmacies participating in TELUS Health Assure have specific responsibilities outlined in the manual:

• Ensuring staff are trained on current claims procedures
• Maintaining accurate records of all claims transactions
• Protecting patient information privacy and security
• Following applicable laws and regulations regarding prescription claims processing
• Keeping pharmacy profile information current in the system
• Responding appropriately to claim responses and rejections
• Providing accurate information to patients about their coverage

System Updates and Notifications

TELUS Health regularly updates the Assure system to improve functionality and comply with changing regulations. The Pharmacy Manual provides information on:

• Notification procedures for system updates
• Impact of major system changes on claims processing
• New features and functionality as they are implemented
• Training resources for updated procedures

Pharmacies should regularly review the manual for updates and implement necessary changes to their claims processing workflows.

Security and Compliance

The security of patient information and compliance with applicable regulations is paramount. TELUS Health Assure claims processing is designed to meet:

• Personal Health Information Protection Act requirements
• Industry security standards for electronic claims processing
• Privacy regulations regarding patient claims data
• Anti-fraud measures to detect and prevent improper claims

Pharmacies must implement appropriate security measures and follow all compliance guidelines when accessing and processing patient claims information.

Best Practices

The TELUS Health Assure Claims Pharmacy Manual highlights best practices for efficient claims processing:

• Regularly verify patient eligibility before dispensing
• Stay informed about formulary updates and coverage changes
• Implement quality control measures to reduce claim errors
• Maintain open communication with patients about their coverage
• Use the full capabilities of the pharmacy management system for claims processing
• Document all interactions related to complex claims scenarios
• Participate in training opportunities to stay current with system functionality

Conclusion

The TELUS Health Assure Claims Pharmacy Manual serves as an essential resource for pharmacies processing prescription benefits claims. By understanding and implementing the guidelines outlined in this manual, pharmacies can optimize their claims processes, reduce rejections and administrative burden, and provide better service to patients. Regular reference to the manual and participation in ongoing training ensures pharmacies remain current with system updates and industry best practices.

TELUS Health provides support for pharmacies implementing these procedures through technical assistance, educational resources, and regular updates to the Pharmacy Manual. Pharmacies are encouraged to develop internal protocols based on these guidelines to ensure consistent and efficient claims processing.